Posterior Cranial Vault Distraction Osteogenesis Utilizing a Posterior-Superior Distraction Vector in the Treatment of Mercedes Benz Pattern Craniosynostosis.

ABSTRACT: Bilateral lambdoid and sagittal synostosis, or Mercedes Benz Syndrome, is a rare complex craniosynostosis resulting in frontal bossing, a tapered posterior fossa, and an anteriorly displaced cranial vertex. Its ideal surgical correction must result in posterior expansion, skull elongation, and caudal repositioning of the vertex. We present a craniometric analysis of skull changes with posterior-superior distraction and introduce a novel craniometric measure: vertex position. In this study, a retrospective review was performed to analyze outcomes of posterior cranial vault distraction osteogenesis (PVDO) using a posterior-superior distraction vector from 2016 to 2019. Cranial vertex position was measured as a fraction of the occipitofrontal diameter from rostral to caudal (0-1.0). Four patients underwent PVDO at mean age 10.61 ±â€Š3.16 months utilizing a posterior-superior distraction vector. Linear distraction distance averaged 30.30 ±â€Š0.90 mm with a mean consolidation period of 3.98 ±â€Š0.72 months. Mean corrected change in intra-cranial volume was 236.30 ±â€Š3.71 mL, at an average rate of 7.81 ±â€Š2.00 mL/mm of distraction. Increases in anterior cranial height (7.83 ±â€Š2.51 mm), middle cranial height (8.43 ±â€Š4.21 mm), posterior cranial height (13.15 ±â€Š7.45 mm), and posterior cranial fossa height (21.99 ±â€Š8.55 mm) were observed. Cranial vertex demonstrated a mean posterior movement of 0.18 ±â€Š0.13. PVDO utilizing a posterior-superior distraction vector for management of nonsyndromic bilateral lambdoid and sagittal synostosis effectively increases intracranial volume and height and provides an esthetic outcome with posterior movement of the cranial vertex.

Management of Paronychia in Patients With Apert Syndrome.

Apert syndrome is a complex congenital syndrome that includes bicoronal craniosynostosis, craniofacial dysmorphologies, cleft palate, hearing loss, spina bifida occulta, cardiac anomalies, and affects the upper and lower extremities-producing complex syndactyly in these patients. Management of the hands yields several challenges and mandates close follow-up to balance repair of complex polysyndactyly with other pressing interventions, such as posterior cranial vault distraction and surgical management of the airway. Our goals of therapy for the hands are to preserve 10 digits, provide sufficient soft tissue coverage, optimize hand function, and minimize the number of surgical interventions. Ideally, surgical management of the hand differences occurs between the ages of 9 months and 2 years, to optimize neurocognitive development. In complex syndactyly observed in patients with Apert syndrome, there are broad, conjoined nail plates that overlie the fused digits, and paronychia occurs frequently. Suppurative infections can delay definitive surgical intervention for the patient's complex syndactyly, and resolution of paronychia is critical. This study aims to propose an effective and safe technique to manage paronychia when it occurs in patients with Apert complex syndactyly and to mitigate the length of delay to definitive polysyndactyly reconstruction. In the context of these patients' need for multiple surgical interventions within the first few years of life, this strategy for preventing or mitigating paronychia can play an important role in streamlining their complex surgical management while avoiding multiple cancellations.

Outcomes Analysis of Gynecologic Oncologic Reconstruction.

BACKGROUND: Defects resulting from gynecologic oncology resections can range from small external defects to total exenterations, requiring complex pelvic reconstruction. We aim to investigate the patient and surgical factors that influence complication rates, reoperation rates, and length of stay. We hypothesize that this patient cohort will have high complication and reoperation rates that are likely most affected by their medical and extirpative surgery factors, with less direct impact from their reconstructive surgery procedures. METHODS: All cases of reconstruction following resection of a gynecological oncology tumor at the University of Wisconsin Hospital over the last 14 years were reviewed. Forty-three patients were identified who required 66 flaps for reconstruction. RESULTS: Mean follow-up period was 19 months. Overall complication rate was 65% and reoperation rate was 33%. Plastic surgery flap-specific complication and reoperation rates were 47% and 19%, respectively, and were not significantly associated with any patient risk factors. Flap reconstruction subtype was not associated with time to complete healing, complication rate, or reoperation. Prior chemotherapy was significantly correlated with increased rate of overall complication (P = 0.0253) and reoperation (P = 0.0448), but prior radiation was not. Mean hospital stay was 11 days (SD ± 9 d). Factors found to be significantly associated with an increase in hospitalization length were increasing number of comorbidities (P = 0.021), exenteration defects (P = 0.0122), myocutaneous flap reconstruction (P = 0.0003), radiation (P = 0.0004), and chemotherapy P = 0.0035). CONCLUSION: This patient cohort has an overall high complication and reoperation rate; however, increasingly complex reconstruction is not associated with significant differences in complication rates or reoperation.

Opioid Prescribing and Consumption Patterns following Outpatient Plastic Surgery Procedures.

BACKGROUND: Opioid overprescribing is a nationwide problem contributing to the current epidemic. This study evaluated opioid consumption, physician prescribing, and patient satisfaction with pain control following outpatient plastic surgery procedures. METHODS: Patients completed a questionnaire during their first postoperative visit. The authors queried about procedure type, quantity of opioids prescribed and consumed, days to opioid cessation, prescription refills, pain scores, use of nonopioid analgesics, and satisfaction with pain control. RESULTS: One hundred seventy patients were included. On average, 26 tablets were prescribed and 13 were consumed. Eighty percent of patients stopped opioids by postoperative day 5. Patients rated their worst pain at 6.1 and follow-up pain at 1.9. Approximately 50 percent of patients consumed nonopioid analgesics. Ninety-six percent of patients were satisfied with their pain control. Similar findings were observed across procedure subcategories. The number of pills prescribed was not correlated with satisfaction but was predictive of worst pain level (p = 0.014). Reduction mammaplasty and abdominoplasty patients consumed the most opioids at 17 and 18.6 pills, respectively; however, first-stage alloplastic breast reconstruction had the largest percentage of patients consuming opioids at the time of follow-up (25 percent) and requiring refills (7 percent). Patients who underwent revision of their reconstructed breast reported the earliest opioid cessation, rated their pain the lowest, and were prescribed the most excess tablets. CONCLUSIONS: Plastic surgeons are prescribing almost double the amount of opioids consumed by patients after outpatient plastic surgery procedures. The results of this study may help guide prescribing practices.

Erratum: Opioid Prescribing and Consumption Trends in Outpatient Plastic Surgery: Erratum.

[This corrects the article DOI: 10.1097/01.GOX.0000533930.73173.70.].

Effect of Drain Placement on Infection, Seroma, and Return to Operating Room in Expander-Based Breast Reconstruction.

INTRODUCTION: There is significant variability in the location and management of drains in breast reconstruction, with most surgeons attempting to shorten the duration of drains while preventing complications possibly related to early removal. The aim of this work was to compare our experiences with placement of 1 versus 2 drains in tissue expander breast reconstruction. METHODS: This is a retrospective cohort study comparing 2 groups of patients after breast tissue expander placement in a complete submuscular pocket and without the use of acellular dermal matrix. In the first group, a single subcutaneous drain was placed; in the second group, both a subcutaneous and a submuscular drain were placed. These groups were evaluated on their relative duration of drain placement, incidence of seroma formation, incidence of infection, and rates of complication necessitating return to operating room (OR). RESULTS: The single-drain group was found to have a significantly shorter duration of drain placement (14.58 vs 22.84 days, P = < 0.01) as well as lower incidence of return to OR for complications after expander placement (8.3% vs 17.6%, P = 0.040), with no difference in rate of seroma formation (6.9% vs 14.7%, P = 0.114) or infection (1.4% in the single-drain group vs 8.8% in the 2-drain group, P = 0.054). CONCLUSIONS: Compared with a two-drain approach, a single subcutaneous drain yields shorter total duration of drain placement and lower rate of complications requiring return to OR while not resulting in higher rates of seroma or infection. It has become our standard approach to use a single subcutaneous drain in patients having a breast tissue expander placed in a submuscular pocket.

Denying the Obvious: Four Extreme Cases of Neglected Tumors.

BACKGROUND: Little is known about the relatively common phenomenon of patients neglecting tumors as part of a denial mechanism to presumably cope with the obvious, outward and clearly visible signs of cancer. As a result of this tumor neglect, disease progression continues unchecked, resulting in excessive tumor growth, invasion of nearby structures, (often) metastatic spread, and significant disfigurement. METHODS: In this case series, we present 4 extreme cases of neglected tumors that posed significant reconstructive challenges and explore the biopsychosocial components of tumor neglect. RESULTS: In this series, we present 4 cases representing various cases of extreme tumor neglect. These 4 cases required multidisciplinary efforts involved in tumor resection, adjuvant treatments and the complex reconstructive efforts after tumor extirpation. CONCLUSIONS: The tumor neglect phenomenon is of broad interest to the field of plastic and reconstructive surgery. Given the complex patient factors that contribute to the extreme state of disease progress upon presentation, all cases required extensive extirpative efforts with complex and challenging reconstructive solutions. Cases of extreme tumor neglect provide insight into the biopsychosocial underpinnings of this specific patient population and have implications for a further understanding of the potential immunoprotective effect of these large, longstanding, and often nonmetastatic tumors.